Healthcare Provider Details

I. General information

NPI: 1609977198
Provider Name (Legal Business Name): GWINNETT CLINIC, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 PHILIP BLVD STE 301
LAWRENCEVILLE GA
30046-8737
US

IV. Provider business mailing address

10600 MEDLOCK BRIDGE RD
DULUTH GA
30097-8404
US

V. Phone/Fax

Practice location:
  • Phone: 678-226-6203
  • Fax: 770-995-3307
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DEEP SHAH
Title or Position: AUTHORIZED OFFICIAL
Credential: MD, MSC
Phone: 770-995-3300